Ocean Gardens Care Center

Based on observations, record review, and interviews conducted during the Recertification survey from 09/20/23 to 09/27/23, the facility did not ensure infection control practices and procedures were maintained. This was evident for 6 (Resident #171, #21, #38, 134, #191 and #173) of 38 total sampled residents. Specifically, Registered Nurse (RN) #7 was observed using the same Blood Pressure (BP) cuff with Resident #171, #21, #38, and #134 without cleaning and disinfecting the BP cuff in between each resident, and RN #3 was observed using the same the Blood sugar/glucose machine (Glucometer) with Resident #191 and #173 without cleaning and disinfecting the Glucometer in between each resident. The findings are: The facility policy titled Multipurpose equipment cleaning, revised 08/2023, documented that all multipurpose equipment must be cleaned and disinfected between resident use, with germicidal/microbial disinfectant disposable wipe. The equipment includes the BP cuff and the Glucometer. On 09/22/23 at 09:54 AM, RN#7 was observed in the dining room with the BP machine. RN #7 did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the Recertification/Complaint survey, the facility did not ensure that a resident was provided with appropriate treatment and services to maintain or improve their ability to ambulate. This was evident for 1 (Resident #129) of 4 residents reviewed for Activities of Daily Living (ADLs) out of 38 sampled residents investigated. Specifically, Resident #129 was not provided with floor ambulation program (FAP) as per Rehab assessments, and in accordance with physician's orders. The findings are: The facility's policy titled FAP dated 01/2022 documented that residents requiring assistance to ambulate will be assigned to a floor ambulation program to be completed by nursing in conjunction with or upon completion of a formal physical therapy program or as deemed necessary by a Physical Therapy assessment or by Nursing. Resident #129 had diagnoses that included Hypertension and Peripheral Vascular Disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview conducted during the Recertification/Complaint survey, the facility did not ensure that the resident and their representatives were provided with a written summary of the baseline care plan (BCP). This was evident for 3 (Residents #85, #164, and #176) of 38 total sampled residents. Specifically, 1) Resident #85 was not provided with a copy of their BCP, 2) Resident #164 was not provided with a copy of their BCP, and 3) Resident #176 was not provided with a copy of their BCP. The findings are: The facility policy titled BCP/Care Plan Summary dated 09/25/2023 documented the facility promotes the resident's right to be informed of the initial plan for the delivery of care and services and to receive a written summary of the baseline care plan. 1) Resident #85 was admitted to the facility 06/01/2023 with diagnoses of coronary artery disease (CAD) and Parkinson's Disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #85 had moderate cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and complaint survey from 9/20/2023 to 9/27/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 of 38 sampled residents (Residents # 32). Specifically, the MDS assessment for Resident # 32 did not reflect Tracheostomy care. The findings are: The facility's policy titled Resident Assessment revised 9/2023 documented the Registered Nurse (RN) conducts or coordinates each assessment with the appropriate participation of health professionals. The policy further states the assessment accurately reflects the resident's status and provide mandated information on each resident's condition. The RN coordinator signs and certifies assessment completion, while everyone who completes a portion of the assessment certifies the accuracy of the assessment. Resident # 32 was admitted to the facility with diagnoses that included Tracheostomy status,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification survey from 9/20/2023 to 9/27/2023, the facility did not develop and implement a comprehensive person-centered care plan (CCP) for a resident. This was evident for 1 (Resident #194) of 38 total sampled residents. Specifically, a CCP related to pain was not developed for Resident #194. The findings are: The facility policy titled CCP dated 12/2022 documented the CCP will be initiated, and appropriate care plans will be in place when there is a change in resident condition. All other episodic care plans will be reviewed as needed to ensure goals and interventions will produce positive resident outcomes. Interdisciplinary development of care plan that will improve the resident's functional abilities and addresses their questions and concerns. Resident # 194 had diagnoses of Unspecified Pain and Schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #194 had mild cognitive impairment. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review conducted during the Recertification and Abbreviated (NY00314342) survey from 09/20/23 to 09/27/23, the facility did not ensure adequate supervision and an environment free from accident hazards for a resident. This was evident in 1 (Resident #166) out of 5 residents reviewed for accidents out of 35 total residents sampled. Specifically, Resident #166 was noted to be missing from Unit 2 and was found on Unit 3, which was a locked unit. The findings are: The facility's policy titled Elopement Prevention dated 06/23 documented that it is the policy of the facility to electronically monitor residents who may tend to wander from the safety of the building, without sacrificing their freedom of mobility or their quality of life. Resident #166 was admitted to the facility with diagnoses that include Depression and Dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #166 was severely cognitively impaired and did not exhibit wandering behavior. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review conducted during the recertification and complaint survey from 9/20/23 to 9/27/23, the facility did not ensure a resident was provided pain management consistent with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 resident (Resident # 194) out of 3 residents reviewed for Pain Management out of 38 total sampled residents. Specifically, Resident # 194 received Tylenol pain medication without ongoing monitoring of the efficacy of the pain management. The findings are: The policy titled Pain Management dated effective 1/2008, latest revision on 8/2023 documented the nurse should document the pain scale reported by the resident and a pain scale after interventions were rendered. Resident #194 had diagnoses of unspecified pain and schizophrenia The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #194 had modified cognitive skills in decision making, received Tylenol pain medication 7 out of 7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure (1). safe food handling and storage was practiced to prevent food-borne illness, and (2). food was prepared, distributed, and served in accordance with professional standards of food service safety. Specifically, a container of Ricotta Cheese was not discarded on or before the expiration date and hand hygiene was not performed prior to handling food after picking an item up off the floor. This was evident during the Kitchen Observation facility task. The findings are: 1) The undated policy and procedure titled Food Labeling, Dating and Rotation of Food Supplies documented that perishable foods such as cottage cheese that are provided an expiration date on the container will be dated when the container is opened. This will not shorten the shelf life of the product but will enable the staff to use this container first. The policy Food and Supply Storage: Precenting Contamination dated 08/2009 documented under supervisor monitoring it will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews during the Recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, (a). 4 residents on oxygen/nebulizer treatment were observed with the tubing not properly labeled and dated to indicate the time the tubing was replaced, (b). 1 resident receiving oxygen therapy was observed with tubing touching the floor on multiple occasions, and (c). the facility did not have a functional site-specific water management plan for Legionella, an annual facility risk assessment for Legionella, a Legionella sampling plan, and the facility did not describe control measures and actions to be taken if control measures were not met. This was evident in 4 of 5 residents reviewed for Respiratory Care area/Oxygen use out of a sample of 35 residents. (Residents #25, Resident #69, Resident #180, & Resident #138) and for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews during the Recertification and Abbreviated survey, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 183 of 218 residents who maintained personal funds accounts at the facility. The findings are: On 5/7/21 at 10:00am, the Administrator presented a surety bond in the amount of $300,000 with an effective date of 11/02/2020 and termination date of midnight 11/02/2021. The facility document titled Patient Account Cash Worksheet dated 5/7/2021 documented the current total amount of resident's funds was $664,363.87. The facility did not ensure that the value of the surety bond covered funds currently held in all residents accounts. On 05/10/21 at 02:54 PM, an interview was conducted with the Resident Fund Account Coordinator (RFAC). The RFAC stated that residents fund is kept in a separate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification and Abbreviated survey, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident for 3 of 4 residents reviewed for Personal Funds out of a sample of 35 residents (Resident #46, #64, and #103). The findings are: The facility policy on Quarterly Statements dated 10/10/2006, last revised 05/2021 documented that resident will be provided with a copy of quarterly statement and will be asked to sign acknowledging receipt of same. For all residents who are unable to sign to acknowledge receipt, two copies will be sent to the legal/designated representative with a cover letter requesting one copy be signed and returned in an enclosed, self-addressed envelope to the facility. (1).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Recertification and Abbreviated survey, the facility did not develop and implement a comprehensive person-centered care plan for a resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, a Comprehensive Care Plan (CCP) that included measurable goals and objectives and interventions was not developed to address the resident's diagnoses of Urinary Tract Infection. This was evident for 1 of 2 residents reviewed for Urinary Catheter out of a total of 35 sampled residents. (Resident # 174) The finding is: The undated facility policy and procedure titled, Comprehensive Care Plan (CCP) with documented problems, goals and approaches will be entered on admission, readmission or whenever a new problem is identified or required revision. Resident # 174 was admitted to facility on 11/17/2020 with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that a Comprehensive Care Plan (CCP) for a resident is reviewed and revised based on changing goals, preferences and needs of the resident. Specifically, the CCP for a resident with an Intravenous Peripherally Inserted Central Catheter (IV PICC) was not reviewed and revised after the catheter was re-inserted. This was evident for 1 of 2 residents reviewed for Infection/Transmission-Based Precautions out of a sample of 35 residents. (Resident #128). The findings are: The facility Policy on Peripheral IV Catheter Flushing dated 01/2021 documented peripheral catheters should be flushed with the prescribed flushing agent following conversion of a continuous IV therapy to intermittent IV therapy. Resident was admitted to the facility on [DATE] with diagnoses that included Hypertension, Multidrug-Resistant Organism (MDRO), Diabetes Mellitus (DM), and Methicillin Resistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews during the Recertification and Abbreviated survey, the facility did not ensure that care and services are provided according to accepted standards of clinical practice. Specifically, the facility did not ensure that a resident with Intravenous Peripherally Inserted Central Catheter (IV PICC) line for antibiotic is provided with care and services to prevent further infection. This was evident for 1 of 2 residents reviewed for Infection/Transmission-Based Precautions out of a sample of 35 residents. (Resident #128). The findings are: The facility policy on Peripheral IV Catheter Flushing dated 01/2021 documented peripheral catheters should be flushed with the prescribed flushing agent following conversion of a continuous IV therapy to intermittent IV therapy. Resident was admitted to the facility on [DATE] with diagnoses that included Hypertension, Multidrug-Resistant Organism (MDRO), Diabetes Mellitus (DM), and Methicillin Resistant Staphylococcus Aureus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that irregularities identified by the pharmacist and forwarded to the facility were acted upon. Specifically, the facility failed to document in the resident's medical record that irregularities identified by the consultant pharmacist had been reviewed and what, if any, action has been taken to address the issues. This was evident for 1 out of 5 residents reviewed for Unnecessary Medications out of a sample of 35 residents. (Resident # 71) The finding is: Resident #71 was admitted to the facility 02/20/2018, with diagnoses that included Non-Alzheimer's Dementia, Seizure Disorder, and Psychotic Disorder. The Significant Change in Status Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident has behavioral symptoms of being fidgety or restless, moving around a lot more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview conducted during the Recertification and Abbreviated survey, the facility did not ensure that medication and biologicals were discarded by expiration date. Specifically, a tube of Glucose gel was observed in a cabinet in the medication room past the expiration date. This was evident on 1 of 5 units reviewed for Medication Storage (Unit 6). The findings are: The undated Horizon Care Center Pharmacy Manual titled Nursing Station Inspections, documented the Pharmacy consultant shall monitor medications stored at all nursing stations on a monthly basis and the purpose to ensure the correct usage, storage, and maintenance of all medications. Procedure for compliance shall be discussed with any nursing staff. The Pharmacon Nursing Station Evaluation form for the 6th Floor dated 03/16/2021 and 04/22/2021was reviewed and annotated with a check mark indicating (yes) to item 4 (a) Are all expired or discontinued drugs removed promptly? On 05/10/2021 at 12:38 PM, an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview during the recertification survey, the facility did not ensure that each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid. This was identified for 2 (Residents #359 and #216) of 3 residents reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification. Specifically, Residents #359 and #216 were not notified of their last covered day of Medicare Part A Service timely as required. The findings are: The undated facility's policy and procedure titled Medicare Prospective Payment System (PPS) documented . Notice of non-coverage must be sent to resident/family member on the last day of medicare coverage. In addition, family member is to be notified via telephone call. Date and time of call is to be documented on the denial letter . 1) Resident #359 has diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview during the recertification survey, the facility did not ensure that a baseline care plan was developed within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This identified for 1 (Resident #250) of 5 residents reviewed for unnecessary medication. Specifically, Resident #250 had an admitting diagnosis of Schizophrenia and was ordered Haldol (an antipsychotic medication). There was no documented evidence that a baseline Comprehensive Care Plan (CCP) for Schizophrenia was developed. The finding is: The undated facility's policy and procedure titled Baseline Care Plan documented This is the policy of this facility to identify the resident's need and develop plan of care within 48 hours from admission . The initial care plans may include the following areas: g. Admitting Diagnosis . The facility's policy and procedure dated March 2010 documented .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the recertification survey, the facility did not ensure that the Mobility care plan was revised for 1 (Resident # 75) of 3 residents reviewed for limited Range of Motion (ROM). Specifically, Resident #75 was placed on a Nursing Rehabilitation Active Range of Motion (AROM) program on 8/6/19 and the Mobility care plan did not include the prescribed treatment. The finding is: The facility policy on range of motion dated 1/09 documented that documentation of actual sites with decreased ROM identified by rehabilitation will be documented by the licensed nurse on the Comprehensive Care Plan which will address the response to the prevention plan instituted. Resident #75 was admitted to the facility on [DATE] with the diagnoses of Peripheral Vascular Disease, Generalized Muscle Weakness, and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #75 had a Brief Interview for Mental Status (BIMS) Score of 7 indicating severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey the facility did not ensure that each resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs). This was identified for one (Resident #172) of three residents reviewed for ADLs. Specifically, Resident #172 had a Physician's order for a standing program to be carried out two times a day (BID). The resident was refusing the standing program; however, nursing supervision and the Rehabilitation Department (Rehab) were not made aware. The finding is: The facility's policy and procedure titled Range of Motion-Prevention and Classification of Residents at Risk for Decrease in Range of Motion, revised 1/2009, documented that the program and the resident's response will be documented on the Certified Nursing Assistant Accountability Record (CNAAR) and the Comprehensive Care Plan (CCP). Resident # 172 was admitted to the facility on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during a recertification survey, the facility did not ensure that each resident received treatment in accordance with professional standards of practice and in accordance with the residents' comprehensive plans of care. This was identified for 1 (Resident #139) of 1 resident reviewed for Insulin Management and 1 (Resident #207) of 2 Residents reviewed for pain management. Specifically, 1) Resident #139 did not receive his prescribed dose of insulin or have his blood sugar reading taken as ordered by the physician; and 2) Resident #207, expressed suicidal ideation and was not assessed for suicide risk by a qualified person for 7 days. Additionally, the attending physician was never notified of the occurrence. The findings are: 1) Resident #139 was admitted to the facility on [DATE] with diagnoses which include Diabetes Mellitus, Hypertension and Schizoaffective Disorder. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the recertification survey, the facility did not provide treatment to maintain or improve range of motion for 1 (Resident # 75) of 3 residents reviewed for limited range of motion (ROM). Specifically, Resident #75 was placed on a Nursing Rehabilitation Active Range of Motion (AROM) program on [DATE] and did not receive AROM as order by the physician. Additionally, the Nursing staff was not in-serviced on the specific instructions for Resident #75's AROM program. The finding is: The facility policy on range of motion protocols and guidelines dated 1/07 documented that AROM would be conducted without the staff member providing hands-on care but rather giving the resident direction, cuing and/or demonstration to the resident. Nursing staff should consult the physical/occupational therapist for instruction/clarification on movements. The facility policy on range of motion dated 1/09 documented that documentation of actual sites with decreased ROM identified by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey the facility did not ensure that the resident environment remains as free of accident hazards, over which the facility has control, as is possible. This was identified for 1 (Resident #258) of 1 resident reviewed for Accident/Incidents (A/I). Specifically, Resident #258 used an aerosol deodorant spray towards a peer and the item was not immediately removed from Resident #258 to prevent the potential for recurrence. The finding is: The facility Resident Peer Abuse/Altercations policy dated 4/17 documented that the facility would notify the attending physician and psychologist that the resident must be evaluated following the incident to determine if they are a danger to self or others. The undated facility policy on Accident/Chemical Hazard documented that the facility will ensure the safety of residents in all instances whether it is physical/verbal abuse, or chemical altercations. Resident #258 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that an annual review of the written standards, policies, and procedures for the Infection Prevention and Control Program (IPCP) was conducted and that the policies and procedures were updated as necessary. The finding is: The facility's Infection Control manual was reviewed and revealed the following: - The overall Infection Control manual was undated. - There were many hand-written post-it notes with information that needed to be incorporated. - There were policies from an unidentified facility. - There were policies that were undated, including Standard Precautions for Infection Control and Blood and Body Fluids Exposure. - There was a policy revised in 2012 for Prevention of Transmission of Multi-Drug Resistant Organisms and a policy revised in 2013 for Hand Hygiene. The Infection Control Registered Nurse (RN) was unavailable for interview. The Director of Nursing Services (DNS) was interviewed on 10/04/19 at 10:35 AM. She stated the Infection Control and Inservice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.